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I learned today in a management meeting at my hospital about some new changes to Medicare/Medicaid that I think everyone needs to know; especially anyone with a compromised immune system.

As of October 1, Medicare/Medicaid will no longer reimburse hospitals for expenses related to the treatment of nosocomial infections (those acquired while in the hospital). Once again, the government agencies are sticking their hand into something they should leave alone. Obviously the thought process behind this is that if you refuse to pay for the expenses, then the hospitals will stop the infections from occuring.

First off, the hospital has little control over the fact that certain populations of patients will acquire infections while in the hospital. It does not matter where a patient is, hospitalized, at home, long term care facility, etc, certain patients are going to get infections. Such patients would include: immunocompromised, patients with artificial airways or artificial ventilatory devices, patients with frequent iv/port/tube/drain access needs, patients who are convalescent, patients who are unable to tend to their own personal hygiene needs, patients with open wounds/burns, patients on multiple antibiotic coverage, patients who are non-compliant, patients who are malnourished, etc, etc, etc....

Secondly, a hospital can have the best laid plans, but it comes down to the individual workers to follow those protocols in order to prevent infections from spreading. Some people do not follow because they are ignorant, apathetic, denialist, clumsy, or even defiant. Every workplace/profession has these people, healthcare is no different. And when you consider some providers who make right at minimum wage, then you get what you pay for.

Thirdly, hospitals have no way of monitoring/controlling what visitors bring into the facility, and how they conduct themselves in private while in the patients room. Again, see above paragraph for how/why visitors might infect the patient.

Here are some things that were discussed in our meeting today in order to avoid/curtail nosocomial infections and subsequent expenses for the treatment of the infections:

1. Increase staffing, education, and programs on infection control. Due to the added expense, we would of course have to increase hospital rates and charges.

2. Greatly restrict the visitation policies. There would be strict limiting on when visitors could come, how many could come (not just at one time, but throughout the hospital admission), the age groups that could come, the health of the visitors that could come, forcing all visitors to wear isolation gear when visiting an at-risk patient, denying visitation all together on at-risk patients, forcing patients and visitor(s) to sign waiver and acceptance for nosocomial infections, requiring that all visitation be strictly supervised (maybe even a 'no patient-visitor physical contact policy'), etc, etc.

3. Refuse to accept Medicare/Medicaid patients.

4. Refuse to accept patients in the high-risk category.

5. Refuse to treat the nosocomial infection, as we are not responsible for treating a non-reimbursable condition that is not life-threatening and is not on your principle admitting diagnosis.

6. Accept Medicare/Medicaid patients and/or high-risk patients only with a waiver and acceptance form signed, guaranteeing payment for nosocomial infections.

7. Treat the nosocomial infection, bill the patient for it, and pursue the debt to the fullest extent of the law.

8. Treat the nosocomial infections, and wait for a class-action lawsuit or legislative lobby to change the regulation.

9. Treat the nosocomial infection and just eat the bill.

All 9 of these options and combinations of these options, plus some, were discussed and considered. It is a shame, that government meddling and it's attempts to "punish" hospitals is going to cause a poor ill patient to suffer. The government rules and regulations already have hospitals hands so tied, it is no longer financially feasible for anyone to even invest in a hospital. Without private enterprise/investments in hospitals, then they will have to be governent/public (ie: tax) supported; and thusly taxes will have to be increased. At any rate, it is the diseased and the poor that will suffer, as they so often do. To make things worse, most private insurance companies will follow whatever Medicare/Medicaid does. So more than likely this non-reimbursement policy will be universal within a few years.

So, watch out for yourself and those you care about when admitted to the hospital, to be sure that strict infection control policies are followed if you/they are Medicare/Medicaid. Remember this new regualtion whenever you vote for candidates and laws; if you don't vote, you need to start! Write your legislators and let them know how you feel about this new regulation.

Last but not least, surely everyone knows that the majority of healthcare providers would never do anything to cause someone to get sick?! Most of us put too much into our education, licensure, maintenance of licensure, and working all sort of bizarre hours, just to see that healthcare can be available to the communities where we live and serve.

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7 weeks post exposure, tested HIV Negative.

Be Kind To Everyone You Meet, For You Do Not Know What Battles They Have Fought That Day.

I don't understand the ability to refuse treatment to a high risk person. I am a high risk person. What would you tell me? Where would you send me? I thought hospitals had an obligation to treat the sick regardless of ability to pay.

On point #5. If you refuse to treat my infection since it was not in my original diagnosis, what happens if I come back to your door to get readmitted for treatment of an infection...thus making it my reason for being there the second time around?

And if your hospital is thinking of doing this, then it is being discussed across the board. So what? Hospitals across the country suddenly decide to stop admitting Medicaid/Medicare patients? How is THAT going to work?

I'm seeing a lot of 6's thru 9's in the future. And how exactly would you get a "guarantee" that I would pay the bill through a waiver? Yeah, I can sign anything...but if I ain't got it- I ain't got it. What would be the course of action then? Reinfect me if I can't come up with the cash?

A hospital does not have to accept any/every patient. A hospital is responsible for treating an immediately life-threatening condition which will result in imminent death, and must treat a woman who is in active labor; regardless of their ability to pay.

No hospital has to accept Medicare/Medicaid, in fact, some do not. Some, have refused to comply with certain Medicare/Medicaid regulations (such as JCAHO accreditation), and only get Medicare/Medicaid reimbursement at a reduced rate. While it is not financially conducieve to refuse Medicare/Medicaid, some do. And note that, refusal of a Medicare/Medicaid patient without just cause, can result in a hospital loosing it's right to collect money on ANY Medicare/Medicaid patient. Just as you can opt out of receiving it, you can also be denied the right to collect it.

Lastly, "I" am not doing any of this to anyone; and I know that you know that , but just wanted to say "Hey, it's not me that's doing this". I am just reporting what was discussed in the meeting today. I said that we would just have to treat the infections and eat the bill, do what we could to reduce the nosocomial rate. I don't actually get any 'vote' on how they "our executives" decide to deal with the situation. It was just a meeting in which we were vetted the information and asked to start brainstorming on soloutions to the problem.

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7 weeks post exposure, tested HIV Negative.

Be Kind To Everyone You Meet, For You Do Not Know What Battles They Have Fought That Day.

I'm just saying this sounds like a disasterous decision. Infections happen all the time in hospitals because, well....it's where sick people go.

I'm not saying "you'' specifically. I'm just asking what would "you" (the hospital) say in such a situation. What would become of all these people? And sure enough- a lot of infections aren't life threatening. But left untreated, a good many of them will become so...no? So then wouldn't you be left with patients returning to your doors with even greater health concerns than they originally were discharged with? Won't that really just snowball costs in the long term?

I'm not from a medical background, obviously. I'm just rattling off the questions that immediately come to mind.

You are exactly right!! It is a disastrous situation in the making! It is what happens when regulators/auditors start meddling into affairs that they have no business trying to meddle with. I was very hurt and angry when we were told that news today. The cost of treating these infections can be enormous, and that is why they are refusing to continue paying for it, that, and as a 'punishment' to healthcare for "allowing" it to happen. You are right, people get sick in the hospital cause that's where sick people go. We having a saying up on the long term acute care floor, once we get a patient rehab'd to the point that we were hoping for, we say, "You better get them out of here before they catch a bug". The problem is that these type of regulatory decisions aren't exactly 'laws'. They get together a bunch of people that are paid to advise HCFA (Medicare/Medicaid) on ways to save money and etc, these people pass these regulations, and that is where it ends. These regulations are not like laws that get voted on by our legislators, or by citizens. So then the poor patients suffer. Not because anyone asked the legislature. Not because anyone asked you (a tax paying citizen). Not because anyone asked me, assistant director of cardiopulmonary medicine and electroneurophysiology diagnostic laboratory. All because the system is so huge, it's dying under it's own weight. We all need to take into deep consideration the stance and interest political candidates have in healthcare in our country, and any few precious bills that we see on our ballots.

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7 weeks post exposure, tested HIV Negative.

Be Kind To Everyone You Meet, For You Do Not Know What Battles They Have Fought That Day.

It is a disastrous situation in the making! All because the system is so huge, it's dying under it's own weight. We all need to take into deep consideration the stance and interest political candidates have in healthcare in our country, and any few precious bills that we see on our ballots.

As a microbiologist in a hospital laboratory i can assure you that Medicares decision to stop reimbursement for nosocomial infections is not going to prevent you from being treated for those infections. This measure is intended to force hospitals to enforce existing infection control programs. At present not enough focus is being given at some hospitals to stop the spread of infection. Withdrawing financial support forces these hospitals to enforce infection control or lose money. Remember that as a patient you must be active in your own care. NEVER allow a health care provider to touch you without washing and gloving. If a health care provider fails to wash before or after leaving you they should be reported to risk management at whatever facility you are attending. The routine should be. 1. Wash upon entering. 2. gloves. 3. Perform procedures. 4. Deglove. 5. Wash before leaving the room. Alcohol washes are just as good if not better than soap and water unless the patient has Clostridium difficile infection in which case soap and water handwashing is required as alcohol does not kill spore forming organisms.

As a microbiologist in a hospital laboratory i can assure you that Medicares decision to stop reimbursement for nosocomial infections is not going to prevent you from being treated for those infections. This measure is intended to force hospitals to enforce existing infection control programs. At present not enough focus is being given at some hospitals to stop the spread of infection. Withdrawing financial support forces these hospitals to enforce infection control or lose money. Remember that as a patient you must be active in your own care. NEVER allow a health care provider to touch you without washing and gloving. If a health care provider fails to wash before or after leaving you they should be reported to risk management at whatever facility you are attending. The routine should be. 1. Wash upon entering. 2. gloves. 3. Perform procedures. 4. Deglove. 5. Wash before leaving the room. Alcohol washes are just as good if not better than soap and water unless the patient has Clostridium difficile infection in which case soap and water handwashing is required as alcohol does not kill spore forming organisms.

And how exactly do you propose that that always gets achieved, micro? Lots of patients are in states of distress, pain or delirium (or perhaps simply too old or cognizant) to stay aware or enforce that. There are lots of scenarios where that isn't a realistic solution.

Yes, I gather what the alleged intention of this measure might be, but I also see that in situations like this the costs invariably get passed on down the line or services get diminished. In other words, it's those on the lowest end of the pole that get hit. I just do not believe that such infections in a hospital setting can be eliminated by doing this.

My thoughts exactly. The patients who are most vulnerable to hospital-caused infections are very often those who are so ill they could not possibly be responsible for enforcing the hospital's hygiene codes.

"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

My thoughts exactly. The patients who are most vulnerable to hospital-caused infections are very often those who are so ill they could not possibly be responsible for enforcing the hospital's hygiene codes.

Ann

This is exactly why the regulators are trying to "force the hands" of health care facilities to enforce their Infection Control plans. The patient should not HAVE to be the enforcers. It should be automatic for the staff to do. Just as it has become automatic (well, mostly) for staff to glove up before touching a bleeding patient for their own protection, they need to glove up for the protection of their patient also.

Now -- I'm not saying that I am in favor of the a blanket reimbursement ban, but I wanted to point out what the "theory" behind this plan is all about. I think there might be better ways to do this and the regulators seem to be using the "hammer" approach.

You are correct micro, the whole purpose of the new regulation is to 'force' hospitals into compliance.Unfortunately, this is not going to accomplish the intended goal. In my original post, I pointed this out, by saying that while hospitals DO have infection control policies in place, some of the staff does not follow the policy due to ignorance, apathy, denial, clumsiness, or pure defiance.Additionally, we cannot control what visitors do while at the hospital.

Ex: Mr. Brown's wife pats on him while visiting him in his room. Mr. Brown has acintobacter, but nobody knows it yet, because the culture hasn't come back. Mrs. Brown doesn't wash her hands good, or at all, and then touches a rail in the elevator when she leaves. Mrs. Green's son touches that same rail in the elevator on his way up to visit her. He gets the a-bacter off of that rail and then goes to visit Mrs. Green, and she ends up getting the a-bacter. We just recently had an acintobacter outbreak in our facility, and in the process, performed weekly environmental cultures. We found the Public Elevator to have more organisms than the Nurses Station.

I see in the future, based on conversations I have had this week, that there will be a lot of bean counters and lawyers looking for loop holes in this regulation. We are going to continue taking high risk patients at our facility, and just eat whatever the cost happens to be. I have no doubt that this will lead to some rather 'creative' DRG coding and etc. Failure to adhere to infection control techniques on patients in strict isolation, is now an automatically fireable offense. Additional employee education and surveillance is under way, as well as patient and visitor education.

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7 weeks post exposure, tested HIV Negative.

Be Kind To Everyone You Meet, For You Do Not Know What Battles They Have Fought That Day.

You are correct micro, the whole purpose of the new regulation is to 'force' hospitals into compliance.Unfortunately, this is not going to accomplish the intended goal. Failure to adhere to infection control techniques on patients in strict isolation, is now an automatically fireable offense. Additional employee education and surveillance is under way, as well as patient and visitor education.

While I agree that this approach isn't going to eliminate hospital-acquired infections, I suspect the goal is around reducing them anyway, which, by your comments here show that it likely WILL impact things.

Now, I absolutely agree with you that this is a terribly ill-advised approach and doesn't do as much for the visitors as it does for the staff, but it still should have a positive impact.

Now, i also think that regulators will always be poking their heads in where they don't belong, as long as someone else is paying. These regulators may be governmental ones, or they may be from insurance companies who demand quicker discharges, etc. At the end of the day, the person with the $$$ will always yield the most power. Again, I'm not saying this is a good thing -- it is simply reality.

We are going to continue taking high risk patients at our facility, and just eat whatever the cost happens to be. I have no doubt that this will lead to some rather 'creative' DRG coding and etc. Failure to adhere to infection control techniques on patients in strict isolation, is now an automatically fireable offense. Additional employee education and surveillance is under way, as well as patient and visitor education.

I hadn't heard about these changes until now, but I'm sure my hospital will be doing the same as yours. Right now Infection Control is a real pain in my ass, as I've had to draw up several new order sets for our new MRSA initiative. One is a standing delegation order meaning that the nurse signs the order and it doesn't have to be signed by a physician. The problem is that certain responses on the admission history and assessment automatically triggers this order to be printed out, then the nurses don't sign it. Since an unsigned order makes the chart incomplete, the IC Coordinator said, well, just have the nurses come down to your department and sign the order. I told her no f-ing way. So when the analysts find an unsigned order, they send it to me, and i package them up and send them to her so SHE can track down the nurses. Either way, it's an extra piece of loose filing that my department has to match up with the chart one way or another. And if they can't sign a simple piece of paper, I can guarantee that some of them are not following precautions the way they should. I think I'm the only one in the whole building that "foams" in and out of ICU, and I'm not even a clinical person!

LOL @ paperwork. I hear ya Basquo.That damn paperwork can be a pain in the arse.They always ask me to sign the "Preadmission Screening Assesment Form" on patients in the long term acute care unit, after the patient is there. I always refuse. I refuse, because they should not ask me to forge my name on a document that says I assessed and accepted the patient before they got there, when I in fact was not ever given the opportunity to do so. If they decide to sidestep our department in their admission and acceptance of a patient, then the patient gets there, and they discover we don't have what we need to care for that patient, I will be damned if I am going to sign a piece of paperwork that says I was given advanced notice of the patients requirements. LOL We also tried to give all patients tobacco cessation education upon admission. When the nurse did the new patient assesment, they were to ask "Do you use tobacco" and check a box marked yes or no, then ask "Do you want access to tobacco cessation information" and check a box marked yes or no. Then the nurse would carry a brochure in the next time they went in. We could not get them to give out the brochures or check the boxes.My job sometimes seems 90% jumping through hoops, and about 10% patient care. I think this leads to some of the apathy in people not performing good infection control techniques.

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7 weeks post exposure, tested HIV Negative.

Be Kind To Everyone You Meet, For You Do Not Know What Battles They Have Fought That Day.

I seem to remember a study done in the last couple years here in the UK (because of the recent MRSA problems) that showed DOCTOR'S TIES were a big source of bugs being spread around.

It makes sense - who is going to wash a silk tie after one wear? Even a polyester one... I don't know anyone that washes their ties at all. Spilled food gets wiped off and if it stains, the tie gets thrown out. I do recall seeing the odd tie here and there at the dry cleaners, but not very often.

The damned things should be outlawed in a medical setting. OK for the boardroom, not ok for the ward(room).

"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts